1
|
Weigand J, Stephens-Novy S, Sachdeva S, Doan TT, Yasso A, Morris SA. Evidence of cardiomyopathy associated with Marfan syndrome in children. Heart 2024; 110:887-891. [PMID: 38816063 DOI: 10.1136/heartjnl-2024-323922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE Marfan syndrome (MFS)-associated cardiomyopathy, defined as ventricular dilation and dysfunction unexplained by volume loading, is not well defined in children. This study evaluated ventricular size and function in paediatric MFS using cardiac MRI (cMRI). METHODS This retrospective cohort study examined patients with MFS <19 years old at first cMRI. Left ventricular (LV) ejection fraction (EF) <55% was considered abnormal, as were z-scores >2. Combined mitral and aortic regurgitation indexed to LV stroke volume <20% defined absent/mild volume load. Biventricular volumes and EF on serial cMRI studies were compared with normative paediatric cMRI values, with measures converted to z-scores as appropriate. Longitudinal changes in volumes and EF were evaluated by mixed linear regression. Associations between ventricular, aortic and mitral characteristics were evaluated. RESULTS 58 patients (60% male) were evaluated. Median age at initial cMRI was 13.6 years (IQR 10.0-15.8 years). Among patients with absent/mild LV volume load at initial cMRI (n=44, 76%), indexed LV end-diastolic volume (EDV) was significantly increased above normative values (median z-score 1.8, IQR 0.6-3.5, p<0.0001) and LVEF was abnormal in 48% (21/44). In the absence of volume loading, mitral valve prolapse (MVP) was associated with larger ventricular volumes and lower LVEF. Among those with serial cMRIs, LVEF and EDV z-scores did not significantly change over a mean follow-up time between cMRI studies of 1.5 years. CONCLUSION Ventricular dilation and reduced EF are common in children with MFS and occur with no/mild LV volume load, suggesting intrinsic cardiomyopathy. MVP may be associated with cardiomyopathy.
Collapse
Affiliation(s)
- Justin Weigand
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Sara Stephens-Novy
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Shagun Sachdeva
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Tam T Doan
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Abigail Yasso
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Shaine A Morris
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
2
|
Baban A, Parlapiano G, Cicenia M, Armando M, Franceschini A, Pacifico C, Panfili A, Zinzanella G, Romanzo A, Fusco A, Caiazza M, Perri G, Galletti L, Digilio MC, Buonuomo PS, Bartuli A, Novelli A, Raponi M, Limongelli G. Unique Features of Cardiovascular Involvement and Progression in Children with Marfan Syndrome Justify Dedicated Multidisciplinary Care. J Cardiovasc Dev Dis 2024; 11:114. [PMID: 38667733 PMCID: PMC11050181 DOI: 10.3390/jcdd11040114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
Marfan syndrome (MIM: # 154700; MFS) is an autosomal dominant disease representing the most common form of heritable connective tissue disorder. The condition presents variable multiorgan expression, typically involving a triad of cardiovascular, eye, and skeletal manifestations. Other multisystemic features are often underdiagnosed. Moreover, the disease is characterized by age related penetrance. Diagnosis and management of MFS in the adult population are well-described in literature. Few studies are focused on MFS in the pediatric population, making the clinical approach (cardiac and multiorgan) to these cases challenging both in terms of diagnosis and serial follow-up. In this review, we provide an overview of MFS manifestations in children, with extensive revision of major organ involvement (cardiovascular ocular and skeletal). We attempt to shed light on minor aspects of MFS that can have a significant progressive impact on the health of affected children. MFS is an example of a syndrome where an early personalized approach to address a dynamic, genetically determined condition can make a difference in outcome. Applying an early multidisciplinary clinical approach to MFS cases can prevent acute and chronic complications, offer tailored management, and improve the quality of life of patients.
Collapse
Affiliation(s)
- Anwar Baban
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Cardiogenetic Center, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00165 Rome, Italy; (G.P.); (A.P.)
| | - Giovanni Parlapiano
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Cardiogenetic Center, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00165 Rome, Italy; (G.P.); (A.P.)
| | - Marianna Cicenia
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.C.); (A.F.)
| | - Michela Armando
- Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children’s Hospital, IRCCS, 00168 Rome, Italy;
| | - Alessio Franceschini
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.C.); (A.F.)
| | - Concettina Pacifico
- Audiology and Otosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Arianna Panfili
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Cardiogenetic Center, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00165 Rome, Italy; (G.P.); (A.P.)
| | - Gaetano Zinzanella
- Ophthalmology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.Z.); (A.R.)
| | - Antonino Romanzo
- Ophthalmology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.Z.); (A.R.)
| | - Adelaide Fusco
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy; (A.F.); (M.C.); (G.L.)
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy; (A.F.); (M.C.); (G.L.)
| | - Gianluigi Perri
- Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.P.); (L.G.)
| | - Lorenzo Galletti
- Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.P.); (L.G.)
| | - Maria Cristina Digilio
- Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.C.D.); (P.S.B.); (A.B.)
| | - Paola Sabrina Buonuomo
- Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.C.D.); (P.S.B.); (A.B.)
| | - Andrea Bartuli
- Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.C.D.); (P.S.B.); (A.B.)
| | - Antonio Novelli
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy;
| | - Massimiliano Raponi
- Medical Direction, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy; (A.F.); (M.C.); (G.L.)
- Centre for Paediatric Inherited and Rare Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London WC1N 3JH, UK
| |
Collapse
|
3
|
Connell PS, Morris SA, Doan TT, Weigand J. Abnormal Left Ventricular Strain Correlates with Left Ventricular Dysfunction but not Aortic Pathology in Marfan Syndrome in Children. Pediatr Cardiol 2023; 44:1536-1545. [PMID: 37505267 DOI: 10.1007/s00246-023-03232-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023]
Abstract
Cardiomyopathy is a complication in adults with Marfan syndrome (MFS). Early recognition of MFS patients at high risk of cardiomyopathy could impact monitoring and treatment. Abnormal ventricular strain has been associated with impaired ventricular function among adults with MFS but remains understudied in children. We retrospectively analyzed a cohort of patients with MFS undergoing cardiac magnetic resonance imaging (CMR) performed in 2003-2018 at age < 19 years. Correlations were evaluated between initial global circumferential strain (GCS) and global longitudinal strain (GLS) and the outcomes of left ventricular ejection fraction (LVEF), aortic root z-score, and vertebral artery tortuosity index corrected for height (VTI-h), all measured from CMR, using Spearman correlation. In those with serial CMR, the ability of ventricular strain to predict development of abnormal LVEF within a 5-year period was assessed. A total of 31 subjects were included (median age at initial CMR 13.5 years, Q1Q3 10.7-16.2 years), with 48% (n = 15) having LVEF < 55%. Worse GCS and worse GLS were associated with lower LVEF (ρ = - 0.629, p < 0.001 and ρ = - 0.411, p = 0.030, respectively). A clinical cutoff of GCS = - 34% predicted LVEF < 55% with sensitivity = 80% and specificity = 50%. Neither GCS nor GLS was associated with aortic root z-score (GCS: p = 0.524; GLS: p = 0.624) nor VTI-h (GCS: p = 0.949; GLS: p = 0.593). Of those with LVEF ≥ 55%, initial GCS and GLS did not differ between those with later normal versus abnormal LVEF (GCS: p = 0.505; GLS: p = 0.232). In this cohort, abnormal LV strain was associated with abnormal LVEF, but not with aortic dilation or low LVEF within the 5 years post-CMR.
Collapse
Affiliation(s)
- Patrick S Connell
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, One Baylor Plaza, 6651 Main St., MC E2060.14, Houston, TX, 77030, USA
| | - Shaine A Morris
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, One Baylor Plaza, 6651 Main St., MC E2060.14, Houston, TX, 77030, USA
| | - Tam T Doan
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, One Baylor Plaza, 6651 Main St., MC E2060.14, Houston, TX, 77030, USA
| | - Justin Weigand
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, One Baylor Plaza, 6651 Main St., MC E2060.14, Houston, TX, 77030, USA.
| |
Collapse
|
4
|
Lodato V, Parlapiano G, Calì F, Silvetti MS, Adorisio R, Armando M, El Hachem M, Romanzo A, Dionisi-Vici C, Digilio MC, Novelli A, Drago F, Raponi M, Baban A. Cardiomyopathies in Children and Systemic Disorders When Is It Useful to Look beyond the Heart? J Cardiovasc Dev Dis 2022; 9:47. [PMID: 35200700 PMCID: PMC8877723 DOI: 10.3390/jcdd9020047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiomyopathy (CMP) is a rare disease in the pediatric population, with a high risk of morbidity and mortality. The genetic etiology of CMPs in children is extremely heterogenous. These two factors play a major role in the difficulties of establishing standard diagnostic and therapeutic protocols. Isolated CMP in children is a frequent finding, mainly caused by sarcomeric gene variants with a detection rate that can reach up to 50% of analyzed cohorts. Complex multisystemic forms of pediatric CMP are even more heterogenous. Few studies in literature take into consideration this topic as the main core since it represents a rarity (systemic CMP) within a rarity (pediatric population CMP). Identifying etiology in this cohort is essential for understanding prognosis, risk stratification, eligibility to heart transplantation and/or mechanical-assisted procedures, preventing multiorgan complications, and relatives' recurrence risk calculation. The previous points represent a cornerstone in patients' empowerment and personalized medical care approach. The aim of this work is to propose a new approach for an algorithm in the setting of the diagnostic framework of systemic pediatric CMP. On the other hand, during the literature review, we noticed a relatively common etiologic pattern in some forms of complex/multisystem CMP. In other words, certain syndromes such as Danon, Vici, Alström, Barth, and Myhre syndrome share a common pathway of directly or indirectly defective "autophagy" process, which appears to be a possible initiating/triggering factor for CMPs. This conjoint aspect could be important for possible prognostic/therapeutic implications in this category of patients. However, multicentric studies detailed functional and experimental models are needed prior to deriving conclusions.
Collapse
Affiliation(s)
- Valentina Lodato
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (G.P.); (F.C.); (M.S.S.); (F.D.)
| | - Giovanni Parlapiano
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (G.P.); (F.C.); (M.S.S.); (F.D.)
- Laboratory of Medical Genetics, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Federica Calì
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (G.P.); (F.C.); (M.S.S.); (F.D.)
| | - Massimo Stefano Silvetti
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (G.P.); (F.C.); (M.S.S.); (F.D.)
| | - Rachele Adorisio
- Heart Failure Clinic-Heart Failure, Heart Transplant, Mechanical Circulatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Michela Armando
- Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - May El Hachem
- Dermatology and Genodermatosis Units, Genetics and Rare Disease Research Division, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Antonino Romanzo
- Ophtalmology Unit, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Maria Cristina Digilio
- Genetics and Rare Diseases Research Division, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Antonio Novelli
- Laboratory of Medical Genetics, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Fabrizio Drago
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (G.P.); (F.C.); (M.S.S.); (F.D.)
| | - Massimiliano Raponi
- Medical Direction, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy;
| | - Anwar Baban
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Pediatric Cardiology and Arrhythmia/Syncope Units, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (G.P.); (F.C.); (M.S.S.); (F.D.)
| |
Collapse
|
5
|
Farooqi N, Metherell LA, Schrauwen I, Acharya A, Khan Q, Nouel Saied LM, Ali Y, El-Serehy HA, Jalil F, Leal SM. Exome Sequencing Identifies a Novel FBN1 Variant in a Pakistani Family with Marfan Syndrome That Includes Left Ventricle Diastolic Dysfunction. Genes (Basel) 2021; 12:1915. [PMID: 34946863 PMCID: PMC8700962 DOI: 10.3390/genes12121915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Cardiomyopathies are diseases of the heart muscle and are important causes of heart failure. Dilated cardiomyopathy (DCM) is a common form of cardiomyopathy that can be acquired, syndromic or non-syndromic. The current study was conducted to explore the genetic defects in a Pakistani family with cardiac disease and features of Marfan's syndrome (MFS). METHODS A family with left ventricle (LV) diastolic dysfunction and MFS phenotype was assessed in Pakistan. The clinical information and blood samples from the patients were collected after physical, cardiovascular, and ophthalmologic examinations. An affected individual (proband) was subjected to whole-exome sequencing (WES). The findings were further validated through Sanger sequencing in the family. RESULTS Through WES and sanger validation, we identified a novel variant NM_000138.4; c.1402A>G in the Fibrillin-1 (FBN1) gene that segregates with LV diastolic dysfunction and MFS. Furthermore, bioinformatic evaluation suggested that the novel variant is deleterious and disease-causing. CONCLUSIONS This study identified for the first time a novel FBN1 variant in a family with LV diastolic dysfunction and MFS in Pakistan.
Collapse
Affiliation(s)
- Nadia Farooqi
- Department of Biotechnology, Faculty of Chemical and Life Sciences, Abdul Wali Khan University, Mardan 23200, Pakistan; (N.F.); (Q.K.); (Y.A.)
| | - Louise A. Metherell
- Centre for Endocrinology, William Harvey Research Institute, Charterhouse Square Campus, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK;
| | - Isabelle Schrauwen
- Center for Statistical Genetics, Gertrude H. Sergievsky Center, Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA; (I.S.); (A.A.); (L.M.N.S.)
| | - Anushree Acharya
- Center for Statistical Genetics, Gertrude H. Sergievsky Center, Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA; (I.S.); (A.A.); (L.M.N.S.)
| | - Qayum Khan
- Department of Biotechnology, Faculty of Chemical and Life Sciences, Abdul Wali Khan University, Mardan 23200, Pakistan; (N.F.); (Q.K.); (Y.A.)
| | - Liz M. Nouel Saied
- Center for Statistical Genetics, Gertrude H. Sergievsky Center, Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA; (I.S.); (A.A.); (L.M.N.S.)
| | - Yasir Ali
- Department of Biotechnology, Faculty of Chemical and Life Sciences, Abdul Wali Khan University, Mardan 23200, Pakistan; (N.F.); (Q.K.); (Y.A.)
| | - Hamed A. El-Serehy
- Department of Zoology, College of Science, King Saud University, Riyadh I1451, Saudi Arabia;
| | - Fazal Jalil
- Department of Biotechnology, Faculty of Chemical and Life Sciences, Abdul Wali Khan University, Mardan 23200, Pakistan; (N.F.); (Q.K.); (Y.A.)
| | - Suzanne M. Leal
- Center for Statistical Genetics, Gertrude H. Sergievsky Center, Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA; (I.S.); (A.A.); (L.M.N.S.)
- Taub Institute for Alzheimer’s Disease and the Aging Brain, Columbia University Medical Center, New York, NY 10032, USA
| |
Collapse
|
6
|
Xu H, Ma N, Guo R, Luo H, Zhang L, Liu D, Zang S, Zhao L, Zhang X, Qiao C. Intrinsic left ventricular impairment in Marfan syndrome: A systematic review and meta-analysis. J Card Surg 2021; 36:4715-4721. [PMID: 34562283 DOI: 10.1111/jocs.16019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intrinsic cardiac impairment in Marfan syndrome (MFS) has been explored in many clinical studies; however, their results have been inconsistent. This meta-analysis aimed to assess the difference in cardiac structure and function between Marfan patients and healthy individuals, and to verify the hypothesis of intrinsic cardiac impairment in MFS. METHODS Electronic searches for studies were performed in the PubMed, Embase, and Cochrane Library databases. Nine studies with 490 patients with MFS and 478 controls were included in the analysis. Age and sex were strictly matched between Marfan patients and healthy controls in every study. RESULTS There was no difference in the left ventricular end systolic diameter index (mean difference [MD]: 0.33; 95% confidence interval [CI]: (-0.24, 0.89); p = 0.26) and left ventricular end diastolic diameter index (MD: 0.18; 95% CI: [-0.47, 0.83]; p = 0.58) between Marfan patients and controls. Marfan patients showed larger left ventricular end systolic volume index (MD: 2.62; 95% CI: [0.27, 4.97]; p = 0.03) and left ventricular end diastolic volume index (MD: 4.16; 95% CI: [2.70, 5.63]; p < 0.01) than the control group. Furthermore, Marfan patients showed a lower left ventricular ejection fraction than healthy people (MD: -2.59%; 95% CI: [-4.64%, -0.54%]; p = 0.01). CONCLUSIONS Intrinsic cardiac impairment was observed in MFS. MFS patients showed the larger left ventricular volume and poorer left ventricular function than matched controls. Considering the potentially adverse impact on cardiac function, intrinsic cardiac impairment in MFS should be considered during the cardiac surgery.
Collapse
Affiliation(s)
- Hao Xu
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Ning Ma
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Ruiming Guo
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Hong Luo
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Liang Zhang
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Donghai Liu
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Suhua Zang
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Lixuan Zhao
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Xin Zhang
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| | - Chenhui Qiao
- Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China.,Heart Transplantation Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan, China
| |
Collapse
|
7
|
García-Izquierdo E, Moñivas-Palomero V, Forteza A, Martín-López C, Torres-Sanabria M, Cia-Mendioroz X, Olivo-Rodríguez C, Navarro-Rico S, Sánchez-Gómez A, Mirelis JG, Cavero MA, Mingo-Santos S. Left atrial strain in the assessment of diastolic function: providing new insights into primary myocardial dysfunction in Marfan syndrome. Int J Cardiovasc Imaging 2021; 37:2735-2745. [PMID: 33871735 DOI: 10.1007/s10554-021-02247-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/14/2021] [Indexed: 01/28/2023]
Abstract
Previous studies using conventional echocardiographic measurements have reported subclinical left ventricular (LV) diastolic abnormalities in patients with Marfan syndrome (MFS). Left atrial (LA) strain allows an accurate categorization of LV diastolic dysfunction. We aimed to characterize LV myocardial performance in a cohort of MFS patients using STE-derived measurements (LV and LA strain) along with conventional echocardiographic parameters. We studied 127 adult patients with MFS (no prior cardiac surgery or significant valvular regurgitation) and 38 healthy controls. We performed detailed echocardiograms and selected left atrial reservoir strain (LASr) as a surrogate of impaired relaxation. Additionally, we searched for possible determinants of LASr in patients with MFS, with a special focus on the elastic properties of the aorta. In spite of lower E-wave, septal and lateral e' velocities and average E/e' ratio in MFS patients, all participants had normal diastolic function according to current guidelines. MFS patients exhibited reduced LV global longitudinal strain (19.3 ± 2.6 vs 21.6 ± 2.1%, p < 0.001) and reduced LASr (32.9 ± 8.5 vs 43.3 ± 7.8%, p < 0.001) compared to controls. In the MFS cohort, we found weak significant (p < 0.05) correlations between LASr and certain parameters: E/A ratio (R = 0.258), E wave (R = 0.226), aortic distensibility (R = 0.222), stiffness index (R = - 0.216), LV ejection fraction (R = 0.214), lateral e' (R = 0.210), LV end-systolic volume index (R = - 0.210), LV global longitudinal strain (R = 0.201), septal e' (R = 0.185). After multivariate analysis, only LV end-systolic volume index and E/A ratio maintained a weak independent association with LASr (R = - 0.220; p = 0.017 and R = 0.199; p = 0.046, respectively). In conclusion, LASr is reduced in patients with MFS, which may represent an early stage of LV diastolic dysfunction. LASr is not determined by the elastic properties of the aorta, suggesting that impaired myocardial relaxation is a primary condition in MFS.
Collapse
Affiliation(s)
- Eusebio García-Izquierdo
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain.
| | - Vanessa Moñivas-Palomero
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Alberto Forteza
- Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Carlos Martín-López
- Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Mario Torres-Sanabria
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Xabier Cia-Mendioroz
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Consuelo Olivo-Rodríguez
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Sara Navarro-Rico
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Andrés Sánchez-Gómez
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Jesús G Mirelis
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Miguel A Cavero
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| | - Susana Mingo-Santos
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 1, 28222, Madrid, Spain
| |
Collapse
|
8
|
Muiño-Mosquera L, De Backer J. Cardiomyopathy in Genetic Aortic Diseases. Front Pediatr 2021; 9:682390. [PMID: 34336739 PMCID: PMC8319542 DOI: 10.3389/fped.2021.682390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
Genetic aortic diseases are a group of illnesses characterized by aortic aneurysms or dissection in the presence of an underlying genetic defect. They are part of the broader spectrum of heritable thoracic aortic disease, which also includes those cases of aortic aneurysm or dissection with a positive family history but in whom no genetic cause is identified. Aortic disease in these conditions is a major cause of mortality, justifying clinical and scientific emphasis on the aorta. Aortic valve disease and atrioventricular valve abnormalities are known as important additional manifestations that require careful follow-up and management. The archetype of genetic aortic disease is Marfan syndrome, caused by pathogenic variants in the Fibrillin-1 gene. Given the presence of fibrillin-1 microfibers in the myocardium, myocardial dysfunction and associated arrhythmia are conceivable and have been shown to contribute to morbidity and mortality in patients with Marfan syndrome. In this review, we will discuss data on myocardial disease from human studies as well as insights obtained from the study of mouse models of Marfan syndrome. We will elaborate on the various phenotypic presentations in childhood and in adults and on the topic of arrhythmia. We will also briefly discuss the limited data available on other genetic forms of aortic disease.
Collapse
Affiliation(s)
- Laura Muiño-Mosquera
- Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium.,Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Julie De Backer
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
9
|
Impact of chest wall deformity on cardiac function by CMR and feature-tracking strain analysis in paediatric patients with Marfan syndrome. Eur Radiol 2020; 31:3973-3982. [PMID: 33355698 PMCID: PMC8128727 DOI: 10.1007/s00330-020-07616-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/21/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022]
Abstract
Objectives To evaluate systolic cardiac dysfunction in paediatric MFS patients with chest wall deformity using cardiac magnetic resonance (CMR) imaging and feature-tracking strain analysis. Methods Forty paediatric MFS patients (16 ± 3 years, range 8−22 years) and 20 age-matched healthy controls (16 ± 4 years, range 11−24 years) were evaluated retrospectively. Biventricular function and volumes were determined using cine sequences. Feature-tracking CMR was used to assess global systolic longitudinal (GLS), circumferential (GCS) and radial strain (GRS). A dedicated balanced turbo field echo sequence was used to quantify chest wall deformity by measuring the Haller index (HI). Results LV volumes and ejection fraction (EF) were similar in MFS patients and controls. There was a trend for lower right ventricular (RV) volume (75 ± 17 vs. 81 ± 10 ml/m2, p = 0.08), RV stroke volume (41 ± 12 vs. 50 ± 5 ml/m2, p < 0.001) and RVEF (55 ± 10 vs. 62 ± 6%, p < 0.01) in MFS patients. A subgroup of MFS patients had an increased HI compared to controls (4.6 ± 1.7 vs. 2.6 ± 0.3, p < 0.001). They demonstrated a reduced RVEF compared to MFS patients without chest wall deformity (50 ± 11% vs. 58 ± 8%, p = 0.01) and controls (p < 0.001). LV GLS was attenuated when HI ≥ 3.25 (- 16 ± 2 vs. - 18 ± 3%, p = 0.03), but not GCS and GRS. LV GLS (p < 0.01) and GCS (p < 0.0001) were attenuated in MFS patients compared to controls, but not GRS (p = 0.31). RV GLS was attenuated in MFS patients compared to controls (- 21 ± 3 vs. - 23 ± 3%, p < 0.05). Conclusion Chest wall deformity in paediatric MFS patients is associated with reduced RV volume, ejection fraction and GLS. Feature-tracking CMR also indicates impairment of systolic LV function in paediatric MFS patients. Key Points • Paediatric Marfan patients demonstrate reduced RV volume and ejection fraction compared to healthy controls. • A concordant attenuation in RV global longitudinal strain was observed in Marfan patients, while the RV global circumferential strain was increased, indicating a possible compensatory mechanism. • Subgroup analyses demonstrated alterations in RV ejection fraction and RV/LV global strain parameters, indicating a possible association of severe chest wall deformity with biventricular dysfunction in paediatric Marfan patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-020-07616-9.
Collapse
|
10
|
Myocardial Function, Heart Failure and Arrhythmia in Marfan Syndrome: A Systematic Literature Review. Diagnostics (Basel) 2020; 10:diagnostics10100751. [PMID: 32992882 PMCID: PMC7599866 DOI: 10.3390/diagnostics10100751] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022] Open
Abstract
Marfan syndrome (MFS) is a heritable systemic connective tissue disease with important cardiovascular involvement, including aortic root dilatation and mitral valve prolapse. Life expectancy in patients with MFS is mainly determined by cardiovascular complications, among which aortic dissection or rupture are most dreaded. In recent years, heart failure and ventricular arrhythmia have drawn attention as extra-aortic cardiovascular manifestations and as additional reported causes of death. Imaging studies have provided data supporting a primary myocardial impairment in the absence of valvular disease or cardiovascular surgery, while studies using ambulatory ECG have demonstrated an increased susceptibility to ventricular arrhythmia. In this paper, current literature was reviewed in order to provide insights in characteristics, pathophysiology and evolution of myocardial function, heart failure and ventricular arrhythmia in MFS.
Collapse
|
11
|
Steijns F, Renard M, Vanhomwegen M, Vermassen P, Desloovere J, Raedt R, Larsen LE, Tóth MI, De Backer J, Sips P. Spontaneous Right Ventricular Pseudoaneurysms and Increased Arrhythmogenicity in a Mouse Model of Marfan Syndrome. Int J Mol Sci 2020; 21:E7024. [PMID: 32987703 PMCID: PMC7582482 DOI: 10.3390/ijms21197024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Patients with Marfan syndrome (MFS), a connective tissue disorder caused by pathogenic variants in the gene encoding the extracellular matrix protein fibrillin-1, have an increased prevalence of primary cardiomyopathy, arrhythmias, and sudden cardiac death. We have performed an in-depth in vivo and ex vivo study of the cardiac phenotype of Fbn1mgR/mgR mice, an established mouse model of MFS with a severely reduced expression of fibrillin-1. Using ultrasound measurements, we confirmed the presence of aortic dilatation and observed cardiac diastolic dysfunction in male Fbn1mgR/mgR mice. Upon post-mortem examination, we discovered that the mutant mice consistently presented myocardial lesions at the level of the right ventricular free wall, which we characterized as spontaneous pseudoaneurysms. Histological investigation demonstrated a decrease in myocardial compaction in the MFS mouse model. Furthermore, continuous 24 h electrocardiographic analysis showed a decreased heart rate variability and an increased prevalence of extrasystolic arrhythmic events in Fbn1mgR/mgR mice compared to wild-type littermates. Taken together, in this paper we document a previously unreported cardiac phenotype in the Fbn1mgR/mgR MFS mouse model and provide a detailed characterization of the cardiac dysfunction and rhythm disorders which are caused by fibrillin-1 deficiency. These findings highlight the wide spectrum of cardiac manifestations of MFS, which might have implications for patient care.
Collapse
Affiliation(s)
- Felke Steijns
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium; (F.S.); (M.R.); (M.V.); (P.V.); (J.D.B.)
| | - Marjolijn Renard
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium; (F.S.); (M.R.); (M.V.); (P.V.); (J.D.B.)
| | - Marine Vanhomwegen
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium; (F.S.); (M.R.); (M.V.); (P.V.); (J.D.B.)
| | - Petra Vermassen
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium; (F.S.); (M.R.); (M.V.); (P.V.); (J.D.B.)
| | - Jana Desloovere
- 4BRAIN, Department of Head and Skin, Ghent University, 9000 Ghent, Belgium; (J.D.); (R.R.); (L.E.L.)
| | - Robrecht Raedt
- 4BRAIN, Department of Head and Skin, Ghent University, 9000 Ghent, Belgium; (J.D.); (R.R.); (L.E.L.)
| | - Lars E. Larsen
- 4BRAIN, Department of Head and Skin, Ghent University, 9000 Ghent, Belgium; (J.D.); (R.R.); (L.E.L.)
- Institute Biomedical Technology, Ghent University, 9000 Ghent, Belgium;
| | - Máté I. Tóth
- Institute Biomedical Technology, Ghent University, 9000 Ghent, Belgium;
| | - Julie De Backer
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium; (F.S.); (M.R.); (M.V.); (P.V.); (J.D.B.)
- Department of Cardiology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Patrick Sips
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium; (F.S.); (M.R.); (M.V.); (P.V.); (J.D.B.)
| |
Collapse
|
12
|
von Kodolitsch Y, Demolder A, Girdauskas E, Kaemmerer H, Kornhuber K, Muino Mosquera L, Morris S, Neptune E, Pyeritz R, Rand-Hendriksen S, Rahman A, Riise N, Robert L, Staufenbiel I, Szöcs K, Vanem TT, Linke SJ, Vogler M, Yetman A, De Backer J. Features of Marfan syndrome not listed in the Ghent nosology – the dark side of the disease. Expert Rev Cardiovasc Ther 2020; 17:883-915. [DOI: 10.1080/14779072.2019.1704625] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yskert von Kodolitsch
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Anthony Demolder
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, VASCERN HTAD European Reference Centre, Ghent, Belgium
| | - Evaldas Girdauskas
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Harald Kaemmerer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich of the Free State of Bavaria, Munich
| | - Katharina Kornhuber
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich of the Free State of Bavaria, Munich
| | - Laura Muino Mosquera
- Department of Pediatric Cardiology and Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Shaine Morris
- Department of Pediatrics-Cardiology, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Enid Neptune
- Division of Pulmonary and Critical Care Medicine and Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Reed Pyeritz
- Departments of Medicine and Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Svend Rand-Hendriksen
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Alexander Rahman
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Hannover
| | - Nina Riise
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Leema Robert
- Department of Clinical Genetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Ingmar Staufenbiel
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Hannover
| | - Katalin Szöcs
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Thy Thy Vanem
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Stephan J. Linke
- Clinic of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Ophthalmological practice at the University Clinic Hamburg-Eppendorf, zentrumsehstärke, Hamburg, Germany
| | - Marina Vogler
- German Marfan Association, Marfan Hilfe Deutschland e.V, Eutin, Germany
| | - Anji Yetman
- Vascular Medicine, Children’s Hospital and Medical Center, Omaha, USA
| | - Julie De Backer
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, VASCERN HTAD European Reference Centre, Ghent, Belgium
| |
Collapse
|
13
|
Renard M, Muiño-Mosquera L, Manalo EC, Tufa S, Carlson EJ, Keene DR, De Backer J, Sakai LY. Sex, pregnancy and aortic disease in Marfan syndrome. PLoS One 2017; 12:e0181166. [PMID: 28708846 PMCID: PMC5510874 DOI: 10.1371/journal.pone.0181166] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/26/2017] [Indexed: 01/13/2023] Open
Abstract
Background Sex-related differences as well as the adverse effect of pregnancy on aortic disease outcome are well-established phenomena in humans with Marfan syndrome (MFS). The underlying mechanisms of these observations are largely unknown. Objectives In an initial (pilot) step we aimed to confirm the differences between male and female MFS patients as well as between females with and without previous pregnancy. We then sought to evaluate whether these findings are recapitulated in a pre-clinical model and performed in-depth cardiovascular phenotyping of mutant male and both nulliparous and multiparous female Marfan mice. The effect of 17β-estradiol on fibrillin-1 protein synthesis was compared in vitro using human aortic smooth muscle cells and fibroblasts. Results Our small retrospective study of aortic dimensions in a cohort of 10 men and 20 women with MFS (10 pregnant and 10 non-pregnant) confirmed that aortic root growth was significantly increased in the pregnant group compared to the non-pregnant group (0.64mm/year vs. 0.12mm/year, p = 0.018). Male MFS patients had significantly larger aortic root diameters compared to the non-pregnant and pregnant females at baseline and follow-up (p = 0.002 and p = 0.007, respectively), but no significant increase in aortic root growth was observed compared to the females after follow-up (p = 0.559 and p = 0.352). In the GT-8/+ MFS mouse model, multiparous female Marfan mice showed increased aortic diameters when compared to nulliparous females. Aortic dilatation in multiparous females was comparable to Marfan male mice. Moreover, increased aortic diameters were associated with more severe fragmentation of the elastic lamellae. In addition, 17β-estradiol was found to promote fibrillin-1 production by human aortic smooth muscle cells. Conclusions Pregnancy-related changes influence aortic disease severity in otherwise protected female MFS mice and patients. There may be a role for estrogen in the female sex protective effect.
Collapse
Affiliation(s)
- Marjolijn Renard
- Center for Medical Genetics Ghent, Ghent University, Ghent, Belgium
- * E-mail:
| | | | - Elise C. Manalo
- Department of Molecular & Medical Genetics and Biochemistry & Molecular Biology, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Sara Tufa
- Micro-Imaging Center, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Eric J. Carlson
- Department of Molecular & Medical Genetics and Biochemistry & Molecular Biology, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Douglas R. Keene
- Micro-Imaging Center, Shriners Hospital for Children, Portland, Oregon, United States of America
| | - Julie De Backer
- Center for Medical Genetics Ghent, Ghent University, Ghent, Belgium
| | - Lynn Y. Sakai
- Department of Molecular & Medical Genetics and Biochemistry & Molecular Biology, Shriners Hospital for Children, Portland, Oregon, United States of America
| |
Collapse
|
14
|
Kiotsekoglou A, Moggridge JC, Child AH, Rask P. The role of advanced echocardiography and cardiovascular magnetic resonance in the assessment of myocardial function in Marfan syndrome-An update. Echocardiography 2017; 34:760-767. [PMID: 28317279 DOI: 10.1111/echo.13517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Cardiovascular assessment of patients with Marfan syndrome has normally focused on the aortic root and vascular manifestations of the disease due to the high risk of aortic dissection. Although primary myocardial impairment has long been suspected in these patients, the evidence has been controversial. Advanced echocardiography and cardiovascular magnetic resonance imaging have proven to be effective, accurate, and more sensitive in the detection of subtle cardiac dysfunction. The application of these techniques to Marfan syndrome over the last 10 years has made significant progress in demonstrating the presence of primary myocardial impairment in these patients, but further work is still required to obtain confirmatory molecular, pathophysiological, and prognostic clinical data. Phenotypic expression of the disease has prognostic value, also suggesting potential effective medical therapy.
Collapse
Affiliation(s)
- Anatoli Kiotsekoglou
- Department of Clinical Physiology, University Hospital of Örebro, Örebro, Sweden
| | - James C Moggridge
- Department of Medical Physics and Bioengineering, University College Hospital, London, United Kingdom
| | - Anne H Child
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Peter Rask
- Department of Clinical Physiology, University Hospital of Örebro, Örebro, Sweden
| |
Collapse
|
15
|
Loeper F, Oosterhof J, van den Dorpel M, van der Linde D, Lu Y, Robertson E, Hambly B, Jeremy R. Ventricular-Vascular Coupling in Marfan and Non-Marfan Aortopathies. J Am Heart Assoc 2016; 5:JAHA.116.003705. [PMID: 27852591 PMCID: PMC5210366 DOI: 10.1161/jaha.116.003705] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Marfan syndrome (MFS) and familial non–syndromal thoracic aortic aneurysm and dissection (ns‐TAAD) are genetic aortopathies causing aortic dilatation with increased aortic stiffness. Left ventricular (LV) contractility and ventricular‐vascular coupling index (VVI) were compared between MFS and ns‐TAAD and determinants of VVI were investigated. Methods and Results Patients with MFS (M 57, F 47) and ns‐TAAD (M 72, F 39) were studied by echocardiography and compared with controls (M 77, F 71). Aortic geometry, hemodynamics, LV work, LV contractility (end‐systolic elastance [Ees]), and VVI were documented. Aortic sinuses were equally dilated in MFS (19.7±2.4) and ns‐TAAD (19.8±1.8) compared to controls (16.2±1.4 mm·m−2, P<0.001). Aortic stiffness index was increased in MFS (9.7±5.1) and ns‐TAAD (10.8±4.7) versus controls (5.4±2.0, P<0.01); LV stroke work was unchanged in MFS (436±74) compared to controls (435±60) but increased in ns‐TAAD (492±109 mJ·m−2P<0.01). The LV Ees was reduced in MFS (1.32±0.19) compared to controls (1.65±0.29 mm Hg·mL−1, P<0.01) but increased in ns‐TAAD (1.83±0.30, P<0.01) and VVI was abnormal in MFS (0.71±0.11) compared to controls (0.62±0.07, P<0.01) and ns‐TAAD (0.62±0.09). Treatment with β‐blockers was associated with partial normalization of VVI in MFS. A VVI ≥0.8 was associated with increased risk of death and heart failure in MFS. Conclusions Left ventricular contractility and ventricular‐vascular coupling are abnormal in MFS but preserved in ns‐TAAD, and are independent of aortic stiffness, consistent with intrinsic impairment of myocardial contractility in MFS.
Collapse
Affiliation(s)
| | | | | | | | - Yaxin Lu
- Sydney Medical School, University of Sydney, Australia
| | | | - Brett Hambly
- Sydney Medical School, University of Sydney, Australia
| | | |
Collapse
|
16
|
von Kodolitsch Y, Rybczynski M, Vogler M, Mir TS, Schüler H, Kutsche K, Rosenberger G, Detter C, Bernhardt AM, Larena-Avellaneda A, Kölbel T, Debus ES, Schroeder M, Linke SJ, Fuisting B, Napp B, Kammal AL, Püschel K, Bannas P, Hoffmann BA, Gessler N, Vahle-Hinz E, Kahl-Nieke B, Thomalla G, Weiler-Normann C, Ohm G, Neumann S, Benninghoven D, Blankenberg S, Pyeritz RE. The role of the multidisciplinary health care team in the management of patients with Marfan syndrome. J Multidiscip Healthc 2016; 9:587-614. [PMID: 27843325 PMCID: PMC5098778 DOI: 10.2147/jmdh.s93680] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Marfan syndrome (MFS) is a rare, severe, chronic, life-threatening disease with multiorgan involvement that requires optimal multidisciplinary care to normalize both prognosis and quality of life. In this article, each key team member of all the medical disciplines of a multidisciplinary health care team at the Hamburg Marfan center gives a personal account of his or her contribution in the management of patients with MFS. The authors show how, with the support of health care managers, key team members organize themselves in an organizational structure to create a common meaning, to maximize therapeutic success for patients with MFS. First, we show how the initiative and collaboration of patient representatives, scientists, and physicians resulted in the foundation of Marfan centers, initially in the US and later in Germany, and how and why such centers evolved over time. Then, we elucidate the three main structural elements; a team of coordinators, core disciplines, and auxiliary disciplines of health care. Moreover, we explain how a multidisciplinary health care team integrates into many other health care structures of a university medical center, including external quality assurance; quality management system; clinical risk management; center for rare diseases; aorta center; health care teams for pregnancy, for neonates, and for rehabilitation; and in structures for patient centeredness. We provide accounts of medical goals and standards for each core discipline, including pediatricians, pediatric cardiologists, cardiologists, human geneticists, heart surgeons, vascular surgeons, vascular interventionists, orthopedic surgeons, ophthalmologists, and nurses; and of auxiliary disciplines including forensic pathologists, radiologists, rhythmologists, pulmonologists, sleep specialists, orthodontists, dentists, neurologists, obstetric surgeons, psychiatrist/psychologist, and rehabilitation specialists. We conclude that a multidisciplinary health care team is a means to maximize therapeutic success.
Collapse
Affiliation(s)
| | | | | | - Thomas S Mir
- Clinic for Pediatric Cardiology, University Heart Centre
| | | | | | | | | | | | | | - Tilo Kölbel
- Clinic of Vascular Medicine, University Heart Centre
| | | | - Malte Schroeder
- Department of Trauma, Hand, and Reconstructive Surgery
- Department of Orthopedics
| | - Stephan J Linke
- Clinic of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bettina Fuisting
- Clinic of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Peter Bannas
- Diagnostic and Interventional Radiology Department and Clinic
| | | | - Nele Gessler
- Clinic of Electrophysiology, University Heart Centre
| | - Eva Vahle-Hinz
- Department of Orthodontics, Center for Dental and Oral Medicine
| | | | | | | | | | - Stefan Neumann
- Business Unit Quality Management, University Medical Center Hamburg-Eppendorf
| | | | | | | |
Collapse
|
17
|
Abnormal heart rate recovery and deficient chronotropic response after submaximal exercise in young Marfan syndrome patients. Cardiol Young 2016; 26:1274-81. [PMID: 26521836 DOI: 10.1017/s1047951115002322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Marfan syndrome patients present important cardiac structural changes, ventricular dysfunction, and electrocardiographic changes. An abnormal heart rate response during or after exercise is an independent predictor of mortality and autonomic dysfunction. The aim of the present study was to compare heart rate recovery and chronotropic response obtained by cardiac reserve in patients with Marfan syndrome subjected to submaximal exercise. METHODS A total of 12 patients on β-blocker therapy and 13 off β-blocker therapy were compared with 12 healthy controls. They were subjected to submaximal exercise with lactate measurements. The heart rate recovery was obtained in the first minute of recovery and corrected for cardiac reserve and peak lactate concentration. RESULTS Peak heart rate (141±16 versus 155±17 versus 174±8 bpm; p=0.001), heart rate reserve (58.7±9.4 versus 67.6±14.3 versus 82.6±4.8 bpm; p=0.001), heart rate recovery (22±6 versus 22±8 versus 34±9 bpm; p=0.001), and heart rate recovery/lactate (3±1 versus 3±1 versus 5±1 bpm/mmol/L; p=0.003) were different between Marfan groups and controls, respectively. All the patients with Marfan syndrome had heart rate recovery values below the mean observed in the control group. The absolute values of heart rate recovery were strongly correlated with the heart rate reserve (r=0.76; p=0.001). CONCLUSION Marfan syndrome patients have reduced heart rate recovery and chronotropic deficit after submaximal exercise, and the chronotropic deficit is a strong determinant of heart rate recovery. These changes are suggestive of autonomic dysfunction.
Collapse
|
18
|
Bradley TJ, Bowdin SC, Morel CFJ, Pyeritz RE. The Expanding Clinical Spectrum of Extracardiovascular and Cardiovascular Manifestations of Heritable Thoracic Aortic Aneurysm and Dissection. Can J Cardiol 2015; 32:86-99. [PMID: 26724513 DOI: 10.1016/j.cjca.2015.11.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/09/2015] [Accepted: 11/09/2015] [Indexed: 01/09/2023] Open
Abstract
More than 30 heritable conditions are associated with thoracic aortic aneurysm and dissection (TAAD). Heritable syndromic conditions, such as Marfan syndrome, Loeys-Dietz syndrome, and vascular Ehlers-Danlos syndrome, have somewhat overlapping systemic features, but careful clinical assessment usually enables a diagnosis that can be validated with genetic testing. Nonsyndromic FTAAD can also occur and in 20%-25% of these probands mutations exist in genes that encode elements of the extracellular matrix, signalling pathways (especially involving transforming growth factor-β), and vascular smooth muscle cytoskeletal and contractile processes. Affected individuals with either a syndromic presentation or isolated TAAD can have mutations in the same gene. In this review we focus on the genes currently known to have causal mutations for syndromic and isolated FTAAD and outline the range of associated extracardiovascular and cardiovascular manifestations with each.
Collapse
Affiliation(s)
- Timothy J Bradley
- Division of Cardiology, Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Sarah C Bowdin
- Division of Cardiology, Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chantal F J Morel
- Fred A. Litwin Family Center in Genetic Medicine, Department of Medicine, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Reed E Pyeritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
19
|
Tae HJ, Petrashevskaya N, Marshall S, Krawczyk M, Talan M. Cardiac remodeling in the mouse model of Marfan syndrome develops into two distinctive phenotypes. Am J Physiol Heart Circ Physiol 2015; 310:H290-9. [PMID: 26566724 DOI: 10.1152/ajpheart.00354.2015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 11/01/2015] [Indexed: 12/21/2022]
Abstract
Marfan syndrome (MFS) is a systemic disorder of connective tissue caused by mutations in fibrillin-1. Cardiac dysfunction in MFS has not been characterized halting the development of therapies of cardiac complication in MFS. We aimed to study the age-dependent cardiac remodeling in the mouse model of MFS FbnC1039G+/- mouse [Marfan heterozygous (HT) mouse] and its association with valvular regurgitation. Marfan HT mice of 2-4 mo demonstrated a mild hypertrophic cardiac remodeling with predominant decline of diastolic function and increased transforming growth factor-β canonical (p-SMAD2/3) and noncanonical (p-ERK1/2 and p-p38 MAPK) signaling and upregulation of hypertrophic markers natriuretic peptides atrium natriuretic peptide and brain natriuretic peptide. Among older HT mice (6-14 mo), cardiac remodeling was associated with two distinct phenotypes, manifesting either dilated or constricted left ventricular chamber. Dilatation of left ventricular chamber was accompanied by biochemical evidence of greater mechanical stress, including elevated ERK1/2 and p38 MAPK phosphorylation and higher brain natriuretic peptide expression. The aortic valve regurgitation was registered in 20% of the constricted group and 60% of the dilated group, whereas mitral insufficiency was observed in 40% of the constricted group and 100% of the dilated group. Cardiac dysfunction was not associated with the increase of interstitial fibrosis and nonmyocyte proliferation. In the mouse model fibrillin-1, haploinsufficiency results in the early onset of nonfibrotic hypertrophic cardiac remodeling and dysfunction, independently from valvular abnormalities. MFS heart is vulnerable to stress-induced cardiac dilatation in the face of valvular regurgitation, and stress-activated MAPK signals represent a potential target for cardiac management in MFS.
Collapse
Affiliation(s)
- Hyun-Jin Tae
- Laboratory of Cardiovascular Science, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Natalia Petrashevskaya
- Laboratory of Cardiovascular Science, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Shannon Marshall
- Laboratory of Cardiovascular Science, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Melissa Krawczyk
- Laboratory of Cardiovascular Science, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Mark Talan
- Laboratory of Cardiovascular Science, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| |
Collapse
|
20
|
von Kodolitsch Y, De Backer J, Schüler H, Bannas P, Behzadi C, Bernhardt AM, Hillebrand M, Fuisting B, Sheikhzadeh S, Rybczynski M, Kölbel T, Püschel K, Blankenberg S, Robinson PN. Perspectives on the revised Ghent criteria for the diagnosis of Marfan syndrome. APPLICATION OF CLINICAL GENETICS 2015; 8:137-55. [PMID: 26124674 PMCID: PMC4476478 DOI: 10.2147/tacg.s60472] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Three international nosologies have been proposed for the diagnosis of Marfan syndrome (MFS): the Berlin nosology in 1988; the Ghent nosology in 1996 (Ghent-1); and the revised Ghent nosology in 2010 (Ghent-2). We reviewed the literature and discussed the challenges and concepts of diagnosing MFS in adults. Ghent-1 proposed more stringent clinical criteria, which led to the confirmation of MFS in only 32%–53% of patients formerly diagnosed with MFS according to the Berlin nosology. Conversely, both the Ghent-1 and Ghent-2 nosologies diagnosed MFS, and both yielded similar frequencies of MFS in persons with a causative FBN1 mutation (90% for Ghent-1 versus 92% for Ghent-2) and in persons not having a causative FBN1 mutation (15% versus 13%). Quality criteria for diagnostic methods include objectivity, reliability, and validity. However, the nosology-based diagnosis of MFS lacks a diagnostic reference standard and, hence, quality criteria such as sensitivity, specificity, or accuracy cannot be assessed. Medical utility of diagnosis implies congruency with the historical criteria of MFS, as well as with information about the etiology, pathogenesis, diagnostic triggers, prognostic triggers, and potential complications of MFS. In addition, social and psychological utilities of diagnostic criteria include acceptance by patients, patient organizations, clinicians and scientists, practicability, costs, and the reduction of anxiety. Since the utility of a diagnosis or exclusion of MFS is context-dependent, prioritization of utilities is a strategic decision in the process of nosology development. Screening tests for MFS should be used to identify persons with MFS. To confirm the diagnosis of MFS, Ghent-1 and Ghent-2 perform similarly, but Ghent-2 is easier to use. To maximize the utility of the diagnostic criteria of MFS, a fair and transparent process of nosology development is essential.
Collapse
Affiliation(s)
| | - Julie De Backer
- Centre for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Helke Schüler
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Diagnostic and Interventional Radiology Department and Clinic, Berlin, Germany
| | - Cyrus Behzadi
- Diagnostic and Interventional Radiology Department and Clinic, Berlin, Germany
| | | | | | - Bettina Fuisting
- Department of Ophthalmology, University Hospital Eppendorf, Hamburg, Germany
| | - Sara Sheikhzadeh
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Meike Rybczynski
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Centre of Cardiology, University Hospital Eppendorf, Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Hospital Eppendorf, Hamburg, Germany
| | | | - Peter N Robinson
- Institute of Medical Genetics and Human Genetics, Charité Universitätsmedizin, Berlin, Germany
| |
Collapse
|
21
|
Abd El Rahman M, Haase D, Rentzsch A, Olchvary J, Schäfers HJ, Henn W, Wagenpfeil S, Abdul-Khaliq H. Left ventricular systolic dysfunction in asymptomatic Marfan syndrome patients is related to the severity of gene mutation: insights from the novel three dimensional speckle tracking echocardiography. PLoS One 2015; 10:e0124112. [PMID: 25901601 PMCID: PMC4406686 DOI: 10.1371/journal.pone.0124112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 02/26/2015] [Indexed: 11/18/2022] Open
Abstract
Background In asymptomatic Marfan syndrome (MFS) patients we evaluated the relationship between the types of fibrillin-1 (FBN1) gene mutation and possible altered left ventricular (LV) function as assessed by three-dimensional speckle tracking echocardiography (3D-STE). Methods and Results Forty-five MFS patients (mean age 24±15 years) and 40 age-matched healthy controls were studied. Genetic evaluation for the FBN1 gene was carried on 32 MFS patients. Gene mutation (n = 15, 47%) was classified as mild when the mutation resulted in nearly normally functioning protein, while mutations resulting in abnormally function protein were considered to be severe (n = 17, 53%). All patients and controls underwent 3D-STE for evaluation of LV function by an echocardiographer blinded to the results of the genetic testing. Compared to controls, MFS patients had significantly lower 3D-STE derived LV ejection fraction (EF, 57.43±7.51 vs. 62.69±4.76%, p = 0.0001), global LV longitudinal strain (LS, 14.85±2.89 vs. 17.90±2.01%, p = 0.0001), global LV circumferential strain (CS, 13.93±2.81 vs. 16.82±2.17%, p = 0.0001) and global LV area strain (AS, 25.76±4.43 vs. 30.51±2.61%, p = 0.0001). Apart from the global LV LS all these parameters were significantly lower in patients with severe gene mutation than in those with mild mutation (p<0.05). In the multivariate linear regression analysis only the type of mutation had a significant influence on the 3D-STE derived LVEF (p = 0.017), global CS (p = 0.005) and global AS (p = 0.03). Conclusions In asymptomatic MFS patients latent LV dysfunction can be detected using 3D STE. The LV dysfunction is mainly related to the severity of gene mutation, suggesting possible primary cardiomyopathy in MFS patients.
Collapse
Affiliation(s)
- Mohamed Abd El Rahman
- Department of Pediatric Cardiology, Saarland University Hospital, Homburg/Saar, Germany
- Department of Pediatric Cardiology, Cairo University, Cairo, Egypt
| | - Denise Haase
- Department of Pediatric Cardiology, Saarland University Hospital, Homburg/Saar, Germany
| | - Axel Rentzsch
- Department of Pediatric Cardiology, Saarland University Hospital, Homburg/Saar, Germany
| | - Julia Olchvary
- Department of Pediatric Cardiology, Saarland University Hospital, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Hospital, Homburg/Saar, Germany
| | - Wolfram Henn
- Department of Human Genetics, Saarland University Hospital, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital, Homburg/Saar, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Hospital, Homburg/Saar, Germany
- * E-mail:
| |
Collapse
|
22
|
Hetzer R, Siegel G, Delmo Walter EM. Cardiomyopathy in Marfan syndrome. Eur J Cardiothorac Surg 2015; 49:561-7; discussion 567-8. [PMID: 25755184 DOI: 10.1093/ejcts/ezv073] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/23/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This report aims to evaluate the existence of primary and secondary cardiomyopathy in patients with Marfan syndrome (MFS) who underwent surgical management for primary cardiovascular sequelae of this genetic disorder. Likewise, we aim to determine whether the myocardium in MFS is susceptible to ischaemia independent of myocardial protection used during surgery. METHODS Between April 1986 and May 2012, 421 patients with MFS were surgically treated for cardiovascular manifestations. Among them, 47 (mean age: 39.45 ± 12.64, median: 36, range: 19-66, years) eventually were surgically treated for cardiomyopathy. They were grouped into A: patients who subsequently developed ischaemic cardiomyopathy and eventually underwent coronary revascularization for coronary artery disease (n = 11); B: patients who subsequently developed end-stage cardiomyopathy for which a mechanical circulatory support device was implanted to support the failing heart (n = 13) and C: patients who subsequently developed end-stage cardiomyopathy (n = 23), among whom 21 underwent primary heart transplantation, while 2 patients are still waiting for donor hearts. RESULTS Retrospective analysis of the medical records of 47 patients revealed the following: In Group A, 3 (27.2%) patients had already existing ischaemic cardiomyopathy before the first various cardiovascular surgeries, while ischaemic cardiomyopathy in the other 8 (72.7%) developed postoperatively. The interval between previous surgery and development of cardiomyopathy was a mean of 8.0 ± 07 years. In Group B, 5 (38.4%) had existing primary cardiomyopathy prior to surgery, while 8 (61.5%) developed end-stage cardiomyopathy postoperatively. The interval between previous surgery and development of cardiomyopathy was a mean of 9.0 ± 4 months. In Group C, 5 (21.7%) had been diagnosed with cardiomyopathy prior to the cardiovascular surgery, while 18 (78.2%) developed end-stage cardiomyopathy postoperatively. The mean interval between previous surgery and development of cardiomyopathy was 3 ± 0.9 years. At a mean follow-up of 9.4 ± 1.37 years, the overall survival rate is 51.8%. Categorized based on the surgical treatment done for cardiomyopathy, survival rates of 54.5% (the mean follow-up of 9.35 ± 1.8 years), 40.1% (mean follow-up of 7.01 ± 2.8 years) and 70% (mean follow-up of 10.5 ± 2.0 years) were seen in Groups A, B and C, respectively. There is no significant difference in survival rates (P = 0.56) among groups. Likewise, the type of myocardial protection and duration of ischaemic times were not significant (P > 0.78) to the development of cardiomyopathy. CONCLUSIONS Our finding supports the existence of cardiomyopathy in a subset of patients with MFS. Marfan cardiomyopathy appears to be independent of the type of myocardial protection and duration of ischaemia.
Collapse
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Günter Siegel
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Eva Maria Delmo Walter
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| |
Collapse
|
23
|
Cook JR, Carta L, Galatioto J, Ramirez F. Cardiovascular manifestations in Marfan syndrome and related diseases; multiple genes causing similar phenotypes. Clin Genet 2014; 87:11-20. [PMID: 24867163 DOI: 10.1111/cge.12436] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 05/23/2014] [Accepted: 05/23/2014] [Indexed: 01/08/2023]
Abstract
Cardiovascular abnormalities are the major cause of morbidity and mortality in Marfan syndrome (MFS) and a few clinically related diseases that share, with MFS, the pathogenic contribution of dysregulated transforming growth factor β (TGFβ) signaling. They include Loeys-Dietz syndrome, Shprintzen-Goldberg syndrome, aneurysm-osteoarthritis syndrome and syndromic thoracic aortic aneurysms. Unlike the causal association of MFS with mutations in an extracellular matrix protein (ECM), the aforementioned conditions are due to defects in components of the TGFβ pathway. While TGFβ antagonism is being considered as a potential new therapy for these heritable syndromes, several points still need to be clarified in relevant animal models before this strategy could be safely applied to patients. Among others, unresolved issues include whether elevated TGFβ signaling is responsible for all MFS manifestations and is the common trigger of disease in MFS and related conditions. The scope of our review is to highlight the clinical and experimental findings that have forged our understanding of the natural history and molecular pathogenesis of cardiovascular manifestations in this group of syndromic conditions.
Collapse
Affiliation(s)
- J R Cook
- Department of Pharmacology and Systems Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | | | | |
Collapse
|
24
|
Cook JR, Carta L, Bénard L, Chemaly ER, Chiu E, Rao SK, Hampton TG, Yurchenco P, Costa KD, Hajjar RJ, Ramirez F. Abnormal muscle mechanosignaling triggers cardiomyopathy in mice with Marfan syndrome. J Clin Invest 2014; 124:1329-39. [PMID: 24531548 PMCID: PMC3934180 DOI: 10.1172/jci71059] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 12/12/2013] [Indexed: 12/11/2022] Open
Abstract
Patients with Marfan syndrome (MFS), a multisystem disorder caused by mutations in the gene encoding the extracellular matrix (ECM) protein fibrillin 1, are unusually vulnerable to stress-induced cardiac dysfunction. The prevailing view is that MFS-associated cardiac dysfunction is the result of aortic and/or valvular disease. Here, we determined that dilated cardiomyopathy (DCM) in fibrillin 1-deficient mice is a primary manifestation resulting from ECM-induced abnormal mechanosignaling by cardiomyocytes. MFS mice displayed spontaneous emergence of an enlarged and dysfunctional heart, altered physical properties of myocardial tissue, and biochemical evidence of chronic mechanical stress, including increased angiotensin II type I receptor (AT1R) signaling and abated focal adhesion kinase (FAK) activity. Partial fibrillin 1 gene inactivation in cardiomyocytes was sufficient to precipitate DCM in otherwise phenotypically normal mice. Consistent with abnormal mechanosignaling, normal cardiac size and function were restored in MFS mice treated with an AT1R antagonist and in MFS mice lacking AT1R or β-arrestin 2, but not in MFS mice treated with an angiotensin-converting enzyme inhibitor or lacking angiotensinogen. Conversely, DCM associated with abnormal AT1R and FAK signaling was the sole abnormality in mice that were haploinsufficient for both fibrillin 1 and β1 integrin. Collectively, these findings implicate fibrillin 1 in the physiological adaptation of cardiac muscle to elevated workload.
Collapse
MESH Headings
- Adult
- Angiotensin II Type 1 Receptor Blockers/pharmacology
- Animals
- Cardiomyopathy, Dilated/etiology
- Cardiomyopathy, Dilated/metabolism
- Cardiomyopathy, Dilated/pathology
- Cardiomyopathy, Dilated/physiopathology
- Child
- Cross-Sectional Studies
- Extracellular Matrix/metabolism
- Fibrillin-1
- Fibrillins
- Focal Adhesion Kinase 1/metabolism
- Humans
- Losartan/pharmacology
- MAP Kinase Signaling System
- Male
- Marfan Syndrome/complications
- Marfan Syndrome/metabolism
- Marfan Syndrome/pathology
- Marfan Syndrome/physiopathology
- Mechanotransduction, Cellular
- Mice
- Mice, Transgenic
- Microfilament Proteins/metabolism
- Myocardium/metabolism
- Myocardium/pathology
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/metabolism
- Organ Size
- Receptor, Angiotensin, Type 1/metabolism
Collapse
Affiliation(s)
- Jason R. Cook
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Luca Carta
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Ludovic Bénard
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Elie R. Chemaly
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Emily Chiu
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Satish K. Rao
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Thomas G. Hampton
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Peter Yurchenco
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | | | - Kevin D. Costa
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Roger J. Hajjar
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| | - Francesco Ramirez
- Department of Pharmacology and Systems Therapeutics and
Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Neuroscience Discovery Core, Mouse Specifics Inc., Framingham, Massachusetts, USA.
Department of Pathology and Laboratory Medicine, Robert W. Johnson School of Medicine, Piscataway, New Jersey, USA
| |
Collapse
|
25
|
Evaluation of cardiac functions of patients with benign joint hypermobility syndrome. Pediatr Cardiol 2014; 35:374-9. [PMID: 24013175 DOI: 10.1007/s00246-013-0785-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/21/2013] [Indexed: 11/27/2022]
Abstract
We sought to investigate whether echocardiography with tissue Doppler imaging identifies myocardial dysfunction in children with benign joint hypermobility syndrome (BJHS). This cross-sectional study enrolled 75 children with BJHS and 70 healthy children. We performed detailed echocardiography in individuals with BJHS without inherited connective tissue disorders. Any congenital or acquired cardiac disease was excluded by clinical and echocardiographic examination. Both groups were similar in terms of age, sex, and body mass index. The diameter of the aortic annulus and sinus valsalva were wider in patients with BJHS. There was no significant differences in ejection fraction or mitral and tricuspid annular plane systolic excursion between the two groups. Pulsed-wave Doppler-derived E/A ratios in mitral and tricuspid valves were similar in both groups. Deceleration time of early mitral inflow was prolonged in patients with BJHS. Mitral and tricuspid annulus Ea velocity were significantly lower in children with BJHS. Ea, Aa, and Ea/Aa ratios in the interventricular septum, left ventricle posterior wall, and right ventricle free wall were lower in patients with BJHS than in the control group. The E/Ea ratio was greater in patients with BJHS than in the control group. Isovolumic relaxation time and right-ventricular (RV) and left-ventricular (LV) myocardial performance indices (MPIs) were greater in patients with BJHS. This study showed the diastolic dysfunction in patients with BJHS. In addition, we detected increased LV and RV MPI. We believe that BJHS may affect proteins of the myocardial cytoskeleton and extracellular matrix.
Collapse
|
26
|
Smooth muscle LDL receptor-related protein-1 deletion induces aortic insufficiency and promotes vascular cardiomyopathy in mice. PLoS One 2013; 8:e82026. [PMID: 24312398 PMCID: PMC3843717 DOI: 10.1371/journal.pone.0082026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 10/28/2013] [Indexed: 11/19/2022] Open
Abstract
Valvular disease is common in patients with Marfan syndrome and can lead to cardiomyopathy. However, some patients develop cardiomyopathy in the absence of hemodynamically significant valve dysfunction, suggesting alternative mechanisms of disease progression. Disruption of LDL receptor-related protein-1 (Lrp1) in smooth muscle cells has been shown to cause vascular pathologies similar to Marfan syndrome, with activation of smooth muscle cells, vascular dysfunction and aortic aneurysms. This study used echocardiography and blood pressure monitoring in mouse models to determine whether inactivation of Lrp1 in vascular smooth muscle leads to cardiomyopathy, and if so, whether the mechanism is a consequence of valvular disease. Hemodynamic changes during treatment with captopril were also assessed. Dilation of aortic roots was observed in young Lrp1-knockout mice and progressed as they aged, whereas no significant aortic dilation was detected in wild type littermates. Diastolic blood pressure was lower and pulse pressure higher in Lrp1-knockout mice, which was normalized by treatment with captopril. Aortic dilation was followed by development of aortic insufficiency and subsequent dilated cardiomyopathy due to valvular disease. Thus, smooth muscle cell Lrp1 deficiency results in aortic dilation and insufficiency that causes secondary cardiomyopathy that can be improved by captopril. These findings provide novel insights into mechanisms of cardiomyopathy associated with vascular activation and offer a new model of valvular cardiomyopathy.
Collapse
|
27
|
Angtuaco MJ, Vyas HV, Malik S, Holleman BN, Gossett JM, Sachdeva R. Early detection of cardiac dysfunction by strain and strain rate imaging in children and young adults with marfan syndrome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1609-1616. [PMID: 23011624 DOI: 10.7863/jum.2012.31.10.1609] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Strain and strain rate imaging have been reported to detect cardiac dysfunction more accurately than conventional methods in adults with Marfan syndrome, but their utility has not been proven in younger patients. We sought to determine whether strain and strain rate imaging would allow early detection of cardiac dysfunction in children and young adults with Marfan syndrome. METHODS Unoperated patients (<30 years) with Marfan syndrome and healthy control participants were prospectively enrolled. Patients with greater than mild mitral or aortic insufficiency were excluded. Left ventricular systolic function was assessed by standard M-mode imaging. The strain and strain rate values were obtained from apical 4-chamber (longitudinal) and parasternal short-axis views at basal and midventricular levels (radial and circumferential). Data from the two groups were compared by a t test. RESULTS Sixteen patients with Marfan syndrome (mean age ± SD, 14.4 ± 6.4 years; range, 5.8-28.9 years) and 26 controls (mean age, 12.4 + 4.4 year; range, 4.1-18.1 years) were enrolled. Demographics and left ventricular end-diastolic dimensions were similar between the patients with Marfan syndrome and the controls. The M-mode-derived shortening fraction was significantly lower in the patients with Marfan syndrome compared to the controls, even though the values were within normal limits. The patients with Marfan syndrome had lower regional radial and circumferential strain rates, but there were no significant difference in strain between the groups. CONCLUSIONS Strain rate imaging may be useful in detection of subclinical changes in cardiac function in patients with Marfan syndrome when conventional echocardiographic parameters are within normal limits. These findings may be clinically important and warrant closer follow-up of these patients to monitor for cardiac dysfunction.
Collapse
Affiliation(s)
- Michael J Angtuaco
- Department of Pediatrics, Division of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, USA
| | | | | | | | | | | |
Collapse
|
28
|
Hoffmann BA, Rybczynski M, Rostock T, Servatius H, Drewitz I, Steven D, Aydin A, Sheikhzadeh S, Darko V, von Kodolitsch Y, Willems S. Prospective risk stratification of sudden cardiac death in Marfan's syndrome. Int J Cardiol 2012; 167:2539-45. [PMID: 22738784 DOI: 10.1016/j.ijcard.2012.06.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 06/09/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Marfan syndrome (MFS) is a variable, autosomal-dominant disorder of the connective tissue. In MFS serious ventricular arrhythmias and sudden cardiac death (SCD) can occur. The aim of this prospective study was to reveal underlying risk factors and to prospectively investigate the association between MFS and SCD in a long-term follow-up. METHODS 77 patients with MFS were included. At baseline serum N-terminal pro-brain natriuretic peptide (NT-proBNP), transthoracic echocardiogram, 12-lead resting ECG, signal-averaged ECG (SAECG) and a 24-h Holter ECG with time- and frequency domain analyses were performed. The primary composite endpoint was defined as SCD, ventricular tachycardia (VT), ventricular fibrillation (VF) or arrhythmogenic syncope. RESULTS The median follow-up (FU) time was 868 days. Among all risk stratification parameters, NT-proBNP remained the exclusive predictor (hazard ratio [HR]: 2.34, 95% confidence interval [CI]: 1.1 to 4.62, p=0.01) for the composite endpoint. With an optimal cut-off point at 214.3 pg/ml NT-proBNP predicted the composite primary endpoint accurately (AUC 0.936, p=0.00046, sensitivity 100%, specificity 79.0%). During FU, seven patients of Group 2 (NT-proBNP ≥ 214.3 pg/ml) reached the composite endpoint and 2 of these patients died due to SCD. In five patients, sustained VT was documented. All patients with a NT-proBNP<214.3 pg/ml (Group 1) experienced no events. Group 2 patients had a significantly higher risk of experiencing the composite endpoint (logrank-test, p<0.001). CONCLUSIONS In contrast to non-invasive electrocardiographic parameter, NT-proBNP independently predicts adverse arrhythmogenic events in patients with MFS.
Collapse
Affiliation(s)
- Boris A Hoffmann
- Department of Cardiology-Electrophysiology, University Heart Center, University Hospital, Hamburg-Eppendorf, Hamburg, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Alpendurada F, Wong J, Kiotsekoglou A, Banya W, Child A, Prasad SK, Pennell DJ, Mohiaddin RH. Evidence for Marfan cardiomyopathy. Eur J Heart Fail 2011; 12:1085-91. [PMID: 20861133 DOI: 10.1093/eurjhf/hfq127] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AIM Marfan syndrome (MFS) is an inherited connective tissue disease which frequently involves the cardiovascular system. The heart can be affected since valvular regurgitation is a common complication. However, there is still debate whether a primary cardiomyopathy exists. Our aim was to evaluate the existence of a Marfan-related cardiomyopathy using cardiovascular magnetic resonance. METHODS AND RESULTS We retrospectively evaluated 68 consecutive adult patients with no cardiovascular surgery or significant valvular regurgitation. Left ventricular and right ventricular volumes, ejection fraction, and mass were estimated and compared with published data on a healthy control population. Patients were also assessed for heart failure, aortic dimensions, and valve disease. One quarter (25.0%) of Marfan patients had reduced left ventricular ejection fraction (LVEF), with 25.0% having increased left ventricular end-diastolic and 30.8% having increased end-systolic volumes. The right ventricular ejection fraction was reduced in 10.3%, with increased right ventricular end-diastolic volumes in 11.8% and increased end-systolic volumes in 13.2%. On univariate analysis, no association was found between reduced LVEF and age, gender, indexed aortic dimensions, presence of mitral valve prolapse, or valve regurgitation. CONCLUSION This study supports the existence of a primary cardiomyopathy in a subgroup of Marfan patients. The biventricular enlargement and dysfunction is usually mild, asymptomatic, and independent from other cardiovascular manifestations. Further studies are needed to assess underlying causes and natural history of this condition. Routine monitoring and treatment in MFS may need to be tailored not only to prevent aortic root expansion but also to support myocardial function.
Collapse
|
30
|
Abstract
Marfan syndrome is a connective-tissue disease inherited in an autosomal dominant manner and caused mainly by mutations in the gene FBN1. This gene encodes fibrillin-1, a glycoprotein that is the main constituent of the microfibrils of the extracellular matrix. Most mutations are unique and affect a single amino acid of the protein. Reduced or abnormal fibrillin-1 leads to tissue weakness, increased transforming growth factor beta signaling, loss of cell-matrix interactions, and, finally, to the different phenotypic manifestations of Marfan syndrome. Since the description of FBN1 as the gene affected in patients with this disorder, great advances have been made in the understanding of its pathogenesis. The development of several mouse models has also been crucial to our increased understanding of this disease, which is likely to change the treatment and the prognosis of patients in the coming years. Among the many different clinical manifestations of Marfan syndrome, cardiovascular involvement deserves special consideration, owing to its impact on prognosis. However, the diagnosis of patients with Marfan syndrome should be made according to Ghent criteria and requires a comprehensive clinical assessment of multiple organ systems. Genetic testing can be useful in the diagnosis of selected cases.
Collapse
|
31
|
|
32
|
The expanding cardiovascular phenotype of Marfan syndrome. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 10:213-5. [DOI: 10.1093/ejechocard/jen311] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
33
|
Halawa A, Brahmbhatt V, Fahrig SA. Initial description of radiofrequency catheter ablation as treatment for atrial flutter in Marfan's syndrome: a case report and literature review. J Interv Card Electrophysiol 2007; 19:37-40. [PMID: 17597390 DOI: 10.1007/s10840-007-9135-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Abstract
Marfan's syndrome is a common connective tissue disease with different musculoskeletal, ophthalmic and cardiac manifestations. Marfan's patients carry increased risk for cardiac arrhythmias. Only three cases of atrial flutter in Marfan's patients are described in the literature. We report a fourth case of a young Marfan's patient who presents with typical atrial flutter after motor vehicle accident. After electrical cardioversion, sinus rhythm was restored but he had recurrent atrial flutter on follow up. The patient then underwent electrophysiological study and successful radiofrequency catheter ablation of the flutter circuit. Since discharge, the patient has had no documented arrhythmias on follow up.
Collapse
Affiliation(s)
- Ahmad Halawa
- Division of Cardiology, James H. Quillen College of Medicine, East Tennessee State University, Johnson, TN 37614, USA.
| | | | | |
Collapse
|
34
|
Rybczynski M, Koschyk DH, Aydin MA, Robinson PN, Brinken T, Franzen O, Berger J, Hofmann T, Meinertz T, von Kodolitsch Y. Tissue Doppler imaging identifies myocardial dysfunction in adults with Marfan syndrome. Clin Cardiol 2007; 30:19-24. [PMID: 17262773 PMCID: PMC6652987 DOI: 10.1002/clc.3] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Successful prevention of aortic complications has lead to improved survival of Marfan syndrome (MFS). With increasing age, however, ventricular arrhythmia and heart failure are emerging as life-threatening manifestations of myocardial dysfunction. HYPOTHESIS We sought to investigate whether echocardiography with tissue Doppler imaging (TDI) identifies myocardial dysfunction in adults with MFS. METHODS We performed two-dimensional (2-D) and Doppler echocardiography with TDI in 141 individuals with suspected MFS and competent heart valves, including 28 persons with MFS who had not undergone surgery and 86 healthy controls without inherited connective tissue disorders. RESULTS Demographic profile, 2-D, mitral and pulmonary venous flow indices, and left ventricular ejection fractions were similar in both groups. Conversely, isovolumic relaxation time (p < 0.001) and deceleration time of E velocity (p = 0.005) were longer, and atrial reversal velocities (p = 0.02), and systolic and early diastolic TD velocities were slower in MFS than in controls (p = 0.01). Multiple linear regression analysis excluded association of reduced systolic and early diastolic TD velocities with mitral valve prolapse or other clinical or echocardiographic features of MFS. CONCLUSIONS Our study identifies reduced systolic and early diastolic TD velocities in adults with MFS. Further studies are mandatory to elucidate whether TD velocities predict arrhythmia and heart failure in MFS.
Collapse
Affiliation(s)
- Meike Rybczynski
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Dietmar H. Koschyk
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Muhammet A. Aydin
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Peter N. Robinson
- Institute of Mathematics and Computer Science in Medicine at the University Hospital Eppendorf, Hamburg, Germany
| | - Tatjana Brinken
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Olaf Franzen
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Jürgen Berger
- Institute of Medical Genetics, Charité University Hospital, at the Humboldt University, Berlin, Germany
| | - Thomas Hofmann
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Thomas Meinertz
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| | - Yskert von Kodolitsch
- Centre of Cardiology and Cardiovascular Surgery, Department of Cardiology and Angiology, Hamburg, Germany
| |
Collapse
|
35
|
Abstract
In recent years, there have been many advances in the treatment of cardiac disease in children with Marfan's syndrome. Early diagnosis, meticulous echocardiographic follow-up and multidisciplinary assessment are essential. Medical treatment with beta-blockers is probably helpful in most children with aortic root dilatation. Research on TGFbeta signalling and the potential treatment role of TGFbeta antagonists may lead to exciting new treatments, but the results of clinical trials are awaited. In managing the cardiovascular complications of Marfan's syndrome, the paediatrician has to walk a difficult path. On the one hand, restrictive lifestyle advice and drugs may need to be prescribed, often in the context of a family history of major surgery or even sudden death. On the other hand, it is essential to encourage the often asymptomatic child to develop and mature as normally as possible.
Collapse
Affiliation(s)
- Alan Graham Stuart
- Congenital Heart Centre, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, UK.
| | | |
Collapse
|
36
|
Kaemmerer H, Oechslin E, Seidel H, Neuhann T, Neuhann IM, Mayer HM, Hess J. Marfan syndrome: what internists and pediatric or adult cardiologists need to know. Expert Rev Cardiovasc Ther 2006; 3:891-909. [PMID: 16181034 DOI: 10.1586/14779072.3.5.891] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Marfan syndrome (MFS) is one of the most frequent connective tissue disorders, showing striking pleiotropism and clinical variability. There is autosomal dominant inheritance with complete penetrance but variable expression. Approximately 25% of MFS patients have no family history of the syndrome and represent sporadic cases due to new mutations. This hazardous condition is often associated with premature cardiovascular death unless surveillance and management are optimized. The fibrillin gene (FBN1) encodes the structure of the connective tissue protein fibrillin. MFS is caused by mutations in the fibrillin gene, located on chromosome 15 at locus 15q21. Fibrillin abnormalities reduce the structural integrity of different body systems, primarily involving the heart valves, blood vessels, lungs, bones, tendons, ligaments, cartilages, eyes, skin, spinal dura and the CNS. Patients with MFS are likely to have too little fibrillin within these structures, resulting in clinically relevant problems. For example, in the aortic wall, deficient fibrillin may trigger progressive aortic ectasia and may result in aortic dissection.
Collapse
Affiliation(s)
- Harald Kaemmerer
- Klinik für Kinderkardiologie und angeborene Herzfehler, Deutsches Herzzentrum München, Klinik an der Technischen UniversiteatLazarettstr. 36D-80636 Munich, Germany.
| | | | | | | | | | | | | |
Collapse
|
37
|
Das BB, Taylor AL, Yetman AT. Left ventricular diastolic dysfunction in children and young adults with Marfan syndrome. Pediatr Cardiol 2006; 27:256-8. [PMID: 16463128 DOI: 10.1007/s00246-005-1139-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Adults with Marfan syndrome (MFS) demonstrate abnormal aortic elastic properties manifest by decreased aortic distensibility and increased aortic stiffness. Left ventricular (LV) diastolic dysfunction has been reported in adults with MFS. The objective of this study was to assess the frequency of LV diastolic dysfunction in a group of children and young adults with MFS and to determine whether diastolic dysfunction is associated with hemodynamic alterations of the aorta. Review of echocardiographic findings in 40 patients with MFS was performed to assess LV size, systolic function, isovolumic relaxation time (IVRT), mitral inflow velocities, deceleration time (DT) of mitral E wave, and aortic root dimension. No patient had significant valvar disease or was on any cardiac medication at the time of study. A group of 40 age and sex-matched healthy subjects undergoing echocardiography served as controls. Significant differences in LV diastolic function were found between MFS patients and controls. MFS patients had prolonged DT and IVRT and decreased mitral E/A ratio, suggesting impaired LV relaxation. No relationship between aortic root dimension and diastolic performance was identified. Left ventricular diastolic dysfunction may be an early marker of myocardial involvement in young MFS patients occurring independently of aortic root dilatation.
Collapse
Affiliation(s)
- B B Das
- Section of Pediatric Cardiology, University of Louisville, Louisville, KY 40202, USA
| | | | | |
Collapse
|
38
|
Lazarevic AM, Nakatani S, Okita Y, Marinkovic J, Takeda Y, Hirooka K, Matsuo H, Kitamura S, Yamagishi M, Miyatake K. Determinants of rapid progression of aortic root dilatation and complications in Marfan syndrome. Int J Cardiol 2006; 106:177-82. [PMID: 16321689 DOI: 10.1016/j.ijcard.2005.01.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2004] [Revised: 01/20/2005] [Accepted: 01/28/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Progressive aortic dilatation has prognostic significance in the Marfan syndrome. METHODS To identify which patients were at high risk of rapid progression, we echocardiographically studied 43 patients (age 22 +/- 14 years) with the mean follow-up period of 5.2 +/- 3.2 years. Aortic diameters, left ventricular (LV) size, fractional shortening, and the severity of aortic and mitral regurgitation were assessed. Transmitral peak early and atrial flow velocities, their ratio and the deceleration time of peak early velocity were also obtained. RESULTS Mean annual increases of aortic diameters were 0.4 +/- 0.3 mm at the annulus, 1.5 +/- 1.3 mm at the sinuses of Valsalva, 0.7 +/- 0.6 mm at the supraaortic ridge and 0.4 +/- 0.4 mm at the proximal ascending aorta. Patients were divided into 2 groups according to the aortic growth rate at the sinuses of Valsalva level: rapid (R, >3% per year, 15 patients) or slow (S, < or =3% per year, 28 patients) progression groups. Measured variables did not show significant differences between the 2 groups except older age, higher blood pressure and more severe aortic regurgitation in group R. Multiple regression analysis identified prolonged deceleration time as the most important variable predicting aortic complications. Aortic dissection occurred more frequently in group R (7 patients, 47%) than in group S (0%, P < 0.001). CONCLUSIONS Marfan patients at older age, with higher blood pressure, and with significant aortic regurgitation were at high risk of progression of aortic dilatation, with the most remarkable increase at the sinuses of Valsalva. Prolonged deceleration time may relate to an increased risk for aortic complications.
Collapse
|
39
|
De Backer JF, Devos D, Segers P, Matthys D, François K, Gillebert TC, De Paepe AM, De Sutter J. Primary impairment of left ventricular function in Marfan syndrome. Int J Cardiol 2005; 112:353-8. [PMID: 16316698 DOI: 10.1016/j.ijcard.2005.10.010] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Revised: 09/26/2005] [Accepted: 10/02/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiovascular involvement in Marfan syndrome is mainly characterized by progressive dilatation of the proximal aorta. Whether left ventricular dysfunction is present in these patients is not clear at present. OBJECTIVES Assess left ventricular function in patients with Marfan syndrome, free of significant valvular heart disease, using a combination of MRI and Tissue Doppler imaging (TDI). METHODS AND RESULTS A total of 26 Marfan patients (mean age=32.0+/-10.9, 12 men) without significant valvular heart disease, and 26 age- and sex-matched controls were studied. Left ventricular volumes and ejection fraction were measured with magnetic resonance imaging. Systolic and diastolic function parameters were assessed using conventional echocardiography and TDI. When compared to controls, Marfan patients showed impairment of left ventricular contractile function as expressed by a reduced ejection fraction (53.5+/-9.0% vs. 59.6+/-6.7%, p=0.009), an increased end-systolic volume (36.0+/-9.5 vs. 29.5+/-6.7 ml/m(2), p=0.007), and reduced peak systolic velocities at the basal septal and lateral myocardial wall (5.2+/-1.4 vs. 6.4+/-1.3 cm/s, p=0.003 and 6.0+/-2.2 vs. 7.5+/-2.3 cm/s, p=0.03, respectively). Diastolic function was impaired with an increased deceleration time of the E wave (171+/-41 ms vs. 141+/-36 ms, p=0.006). Peak early diastolic velocity at the mitral valve annulus was significantly lower (9.6+/-2.4 cm/s vs. 11.9+/-3.3 cm/s, p=0.006). CONCLUSION These data provide evidence for mild, but significant impairment of left ventricular systolic and diastolic function in Marfan patients, not related to valvular heart disease.
Collapse
Affiliation(s)
- Julie F De Backer
- Department of Medical Genetics, Ghent University Hospital, Gent Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Meijboom LJ, Timmermans J, van Tintelen JP, Nollen GJ, De Backer J, van den Berg MP, Boers GH, Mulder BJM. Evaluation of left ventricular dimensions and function in Marfan's syndrome without significant valvular regurgitation. Am J Cardiol 2005; 95:795-7. [PMID: 15757617 DOI: 10.1016/j.amjcard.2004.11.042] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2004] [Revised: 11/10/2004] [Accepted: 11/10/2004] [Indexed: 11/16/2022]
Abstract
Left ventricular dimensions and systolic function were studied using echocardiography in 234 patients with Marfan's syndrome without significant valvular regurgitation. Left ventricular dimensions and systolic function were found to be normal in most patients with Marfan's syndrome. Some involvement of the left ventricle may have been present in a small group of these patients. No patients, however, fulfilled the criteria for dilated cardiomyopathy.
Collapse
Affiliation(s)
- Lilian J Meijboom
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
The Marfan syndrome is an autosomal dominant disorder of connective tissue, caused by mutations in the FBN1 gene on chromosome 15. More than 500 mutations have been identified and almost all are unique to an affected individual or family. Genotype--phenotype correlations in the Marfan syndrome have been complicated by the large number of unique mutations reported, as well as by clinical heterogeneity among individuals with the same mutation. A relatively unknown cardiovascular manifestation of Marfan syndrome is dilatation of the main pulmonary artery. Of 50 patients with Marfan syndrome, MR imaging showed in 74% patients an enlarged pulmonary artery root above the upper limit of normal. Aortic elasticity determined by measurement of local distensibility and flow wave velocity with MR imaging is decreased in non-operated patients with Marfan syndrome. Aortic distensibility of the thoracic descending aorta appeared to be the strongest predictor for descending aortic complications. Over the past 30 years improvement of diagnostic modalities and aggressive medical and surgical therapy, have resulted in considerable improvement of life expectancy of patients with Marfan syndrome. Further studies are needed to investigate the role of modulating genes and genotype--phenotype correlations. Long-term follow-up studies may reveal the prognostic significance of aortic elasticity and may identify patients at risk of aortic complications.
Collapse
Affiliation(s)
- G J Nollen
- Department of Cardiology, Academic Medical Center, Room B2-240, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | | |
Collapse
|
42
|
Lazarević A, Nakatani S. Echocardiographic evaluation of left ventricle function in the Marfan syndrome: Relation to progression of aortic root dilatation. SCRIPTA MEDICA 2004. [DOI: 10.5937/scrimed0401001l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|
43
|
Porciani MC, Giurlani L, Chelucci A, Pepe G, Giusti BH, Brunelli T, Attanasio M, Martinucci P, Fattrori R, Abbatea R, Gensini GF. Diastolic subclinical primary alterations in Marfan syndrome and Marfan-related disorders. Clin Cardiol 2002; 25:416-20. [PMID: 12269520 PMCID: PMC6654107 DOI: 10.1002/clc.4960250905] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2001] [Accepted: 11/13/2001] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The extracellular matrix tissue of the myocardium importantly contributes to left ventricular (LV) performance. Inherited connective tissue disorders related to the FBN1 gene could involve cardiac interstitium resulting in functional abnormalities. HYPOTHESIS To disclose a primary involvement of myocardium, LV function was studied in 28 patients affected by Marfan syndrome or Marfan-related disorders: 20 Marfan and 8 MASS (Mitral valve prolapse, Myopia, Aortic dilatation, Skeletal involvement, Skin striae) and in 28 healthy, age and gender-matched controls. No valvular regurgitation or any other cardiac alterations were present. METHODS Echocardiographic study was performed to investigate LV systolic and diastolic function. RESULTS No statistically significant differences were observed between patients and the control group in LV dimensions, systolic function parameters (ejection and shortening fraction), and some diastolic function parameters (E peak, A peak, E/A), while statistically significant differences were found between patients and the control group in LV mass (128.7 +/- 46.6 vs. 83.7 +/- 14.5 g/m2, p<0.008), in isovolumic relaxation time (102.0 +/- 24.0 vs. 80.1 +/- 11.2 ms, p<0.016), and in deceleration time of the E wave (127.5 +/- 19.3 vs. 208.6 +/- 24.5 ms, p<0.001) and the A wave (66.4 +/- 8.2 vs. 87.5 +/- 23.4 ms, p <0.008). CONCLUSIONS These data show an unusual pattern of transmitral diastolic flow in which a decreased ventricular compliance and reduced myocardial relaxation coexist. Thus, in Marfan syndrome and in Marfan-related disorders, subclinical diastolic alterations are present independent of valvular disease and might represent an early marker of primary myocardial involvement.
Collapse
|
44
|
Ninomiya M, Takamoto S, Kotsuka Y, Miyairi T, Morota T, Kubota H. Midterm results after aortic valve-sparing operation. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2001; 49:706-10. [PMID: 11808092 DOI: 10.1007/bf02913509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We have conducted aortic valve-sparing operation for patients having aortic root dilatation and almost normal aortic valve leaflets since August 1998, and here report midterm results. METHODS Patients with dilated aortic annulus or Marfan's syndrome were treated with reimplantation, and the remaining patients with remodeling. Either 24 or 26 mm graft was selected based on aortic annular diameter and leaflet size. Aortic valve competence was assessed regularly with echocardiography. RESULTS Five patients (age: 29 +/- 13 yr), including 4 with Marfan's syndrome, had undergone reimplantation, and 3 (age: 46 +/- 18 yr) remodeling by December 2000. Mean follow-up was 18 (range: 10-32) months, and no postoperative death has occurred and no reintervention has been required thus far. All the patients in the remodeling group showed only a small pressure gradient through the aortic valve and decreased left ventricular diameter. Two in the reimplantation group showed a pressure gradient exceeding 20 mmHg. Two Marfan's syndrome patients in the reimplantation group showed slightly increased diastolic left ventricular diameter and 3 slightly increased systolic left ventricular diameter. Although aortic regurgitation had diminished in all patients by discharge, moderate aortic regurgitation recurred in 1 non-Marfan's syndrome patient in the reimplantation group because of degenerated aortic valve. CONCLUSION Although postoperative aortic valve function was not perfect in all patients undergoing reimplantation, midterm results after aortic valve-sparing operation were generally satisfactory. Proper selection of patients, procedures, and graft size was thought to be important to ensure a favorable surgical outcome.
Collapse
Affiliation(s)
- M Ninomiya
- Department of Cardiothoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | | | | | | | | |
Collapse
|